Acute pulmonary embolism (PE) is a potentially life-threatening disease with an overall 3-month mortality rate that exceeds 15%, with right ventricular (RV) dysfunction as the most common cause of death (1). The 30-day mortality rate in patients with massive PE, defined as cardiogenic shock or a systemic systolic pressure < 90 mm Hg, exceeds 30%. In patients with massive PE, systemic thrombolysis (2) or surgical embolectomy (3-5) in addition to anticoagulation may be life-saving, facilitating rapid reversal of RV failure and cardiogenic shock. Catheter-directed thrombolysis aims to accelerate clot lysis and achieve rapid reperfusion of pulmonary arteries (6). Rapid recanalization of pulmonary arteries by thrombolysis (7,8) or embolectomy (4) may improve functional class, decrease the risk of recurrence, and prevent chronic thromboembolic pulmonary hypertension. However, approximately 35% patients are not eligible for thrombolysis because of major contraindications, such as recent surgery, trauma, or cancer (9). PE thrombolysis is accompanied by a particularly high risk of bleeding complications. Among 304 patients from the International Cooperative Pulmonary Embolism registry (ICOPER) who received PE thrombolysis, 66 (21.7%) suffered major bleeding and 9 (3.0%) had intracranial bleeding (1).